PrEP'ing: Are You Ready? Doctors and Advocates Are Gearing Up to Bring Truvada PrEP to People at Greatest Risk of Infection

Chicago

In Chicago, Howard Brown Health Center (HBHC), which serves the LGBT (lesbian, gay, bisexual, and transgender) community, does not have a demonstration project per se. Rather, the center is making PrEP part of its primary care services. It has created a protocol for staff training so that everyone can be on the same page about who makes a good candidate for PrEP, said Kristin Keglovitz, P.A., HBHC's medical director. She said the clinic's PrEP protocol will be a multidisciplinary model involving the services of counselors in addition to prescribers. HBHC has already prescribed PrEP and even participated in the iPrEx study, she said.

Last year she prescribed PEP twice to a woman with an HIV-positive partner before telling the patient she might be better off on PrEP. It's a strategy that's backed by research showing that people taking multiple courses of PEP often go on to become infected, because they are at continuing risk for the virus.

"As an organization, and for myself as a provider, we definitely support PrEP," said Keglovitz. "It's a big milestone for prevention."

She said the strategy is "obviously not for everybody," and not a replacement for condoms. "Prevention messages will be crucial," she said.

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What Now?

The FDA advisory committee recommended that PrEP be approved for three specific risk groups -- men who have sex with men, HIV-negative partners of HIV-positive people, and others at high risk of acquiring HIV through sex. It noted that "regular HIV testing, adherence, and behavioral counseling on safer sex practices, including condom use, are essential components of healthcare delivery around PrEP."

All advocates are beating the drum for using condoms along with PrEP. Whether PrEP users out in the real world do or not remains to be seen.

But with all the unknowns surrounding PrEP, there is perhaps one true take-home message from studies and advocates alike: PrEP doesn't work if you don't take it.

Sitting on the FDA advisory committee and voting to recommend Truvada PrEP for approval, community representative Daniel Raymond of the Harm Reduction Coalition in New York City eloquently reminded everyone that, "This is the 25th anniversary of the AIDS Coalition to Unleash Power [ACT UP] and part of the legacy of that movement is empowering patients about learning and mastering the science and sharing it within our respective communities. I think that PrEP gives us the opportunity to do that all over again ... just as responsibly as we've been trying to do for the last 25 years."

Clearly, community awareness is as crucial as ever.

What You Should Know Before PrEP

You need to test HIV-negative before going on PrEP (pre-exposure prophylaxis or prevention).

This may require multiple testing (for example, testing HIV-negative three months in a row).

It's widely believed that PrEP should include the use of condoms and behavioral modification (finding ways to lessen the risk of infection).

It is possible that not using condoms along with PrEP may allow for the risk of infection, possibly negating the effects of PrEP altogether.

Other serious infections can occur without a condom and are epidemic in the gay community: hepatitis C, syphilis, and gonorrhea. (Remember that gonorrhea is also spread through oral sex.)

People who become HIV-positive while on Truvada PrEP risk the development of drug resistance. In studies, the only risk of drug resistance seen was in individuals who were already positive at the time of starting PrEP but didn't know it or people who were infected with an already drug-resistant strain of HIV.

Health care providers might consider supplementing vitamin D and calcium in PrEP patients. Some patients may also benefit from DEXA bone scans before and during treatment.

Research continues to investigate the best uses of PrEP, such as the possibility of less than daily usage and the use of other medications besides Truvada. Other biological prevention methods such as microbicides are also being studied.

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